Iconoclast: Abraham Flexner and a Life in Learning
- Book Review,
by Thomas Neville Bonner
From the New England Journal of Medicine, December 19, 2002
Iconoclast is a thoughtful, wonderfully crafted, solidly researched account of an uncommon life that far exceeds Abraham Flexner's association with reform in medical education. Born in Louisville, Kentucky, in 1866, Flexner (Figure) was one of nine children of German-Jewish immigrants who expected extraordinary achievement from each of their children. By 19 years of age, he was a graduate of Johns Hopkins and passionate about learning; he was a firm believer that education should be marked by small classes, personal attention, and hands-on teaching -- characteristics that he would reproduce throughout his lifetime in many settings. After graduation, he returned to Louisville and developed a school that came to be known as "Mr. Flexner's School." There, he tested his ideas and found that they worked: his graduates were accepted at leading colleges and entered college at very young ages. He soon gained national attention, and in 1908, he published his first book, The American College, an "unrelievedly critical attack on American higher education," as Bonner describes it. One of his fiercest critiques focused on the lecture mode, which enabled colleges to "handle cheaply by wholesale a large body of students that would be otherwise unmanageable and [to give] the lecturer time for research." Flexner's writing attracted the attention of Henry Pritchett, president of the Carnegie Foundation, who was looking for someone to lead a series of studies of professional education. Flexner was his first choice, despite the fact that he had never been inside a medical school. At that time, there were 155 medical schools in North America with wildly diverse admissions, curricular, evaluative, and graduation requirements. Flexner visited all of them; in one month alone, he inspected 30 schools in 12 cities. Some of his descriptions still ring true: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated." Although the 1910 report became famous for its stinging description of particular medical schools -- he referred to Chicago and its 14 medical schools, for example, as "a disgrace to the State whose laws permit its existence . . . indescribably foul . . . the plague spot of the nation" -- it was largely successful in creating a single model of medical education characterized by a philosophy that is still current. "An education in medicine," wrote Flexner, "involves both learning and learning how; the student cannot effectively know, unless he knows how." Although the report is more than 90 years old, many of its recommendations are still relevant -- particularly those concerning the physician as a "social instrument . . . whose function is fast becoming social and preventive, rather than individual and curative." A less well-known recommendation, but one that Flexner promoted unrelentingly, was for the creation of full-time clinical appointments in medical schools. Under this system, faculty members would become "true university teachers, barred from all but charity practice, in the interest of teaching." This was a campaign that Flexner pursued for years, despite opposition from "virtually all clinicians across the country." The remainder of Flexner's professional life was no less accomplished. Soon after the release of the 1910 Carnegie report, he set off to Europe to conduct a similar study of medical education there, and by the time of its publication, his work was, according to Bonner, "nearly as well known in Europe as in America." Working for the Rockefeller Foundation's General Education Board, he developed the Lincoln School in 1916 in cooperation with the faculty at Teachers College of Columbia University. Next, with funding from the Rockefeller Foundation, he worked toward restructuring the nation's medical schools, which enabled him, writes Bonner, "to exert a decisive influence on the course of medical training and to leave an enduring mark on some of the nation's most renowned schools of medicine," including Johns Hopkins, Yale, the University of Chicago, Columbia, Vanderbilt, and Washington University. In this second round of critique, he was concerned that "the imposition of rigid standards by accrediting groups was making the medical curriculum a monstrosity," with medical students moving through it with "little time to stop, read, work or think." In the mid-1920s, Flexner left medical education and renewed his interest in the "direction and purpose of the American college and university," which resulted in Universities: American, English, German, published in 1930. The book, which, says Bonner, "provoked the most intense debate on the purposes of a university since the late 19th century," railed against the "growth of big-time athletics, student governments, and other activities that made a mockery of serious learning." "Intellectual inquiry," Flexner argued again and again, "not job training, [is] the purpose of the university." One of his final projects was the establishment of the Institute for Advanced Studies at Princeton, which would be a "graduate university in the highest possible sense" and would "elevate the status of faculty members in America." Bonner's labors have produced a critical, insightful portrait of Abraham Flexner as a brilliant, tireless, extraordinarily persuasive visionary. In addition to detailed portraits of the man "at the vortex of swiftly moving scientific, educational, and philanthropic currents" in higher education in the United States, Bonner also provides an account of Flexner's personal life with his remarkable family of origin and the family he and his wife Anne created even as they both pursued demanding careers that were often challenging to family life. For all of us in academic medicine, Iconoclast offers a learned portrait of the distance traveled in medical education during the past 100 years, along with consideration of the curricular and pedagogical problems that persist. Flexner was, and perhaps continues to be, "the severest critic and the best friend American medicine ever had." Delese Wear, Ph.D.Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
Review
" Iconoclast captures the boldness as well as the sweeping impact of Flexner's work in the field of American education in the first half of the twentieth century. "--Adam R. Nelson, Paedagogica Historica
Review
"This is a brilliant, beautifully crafted, and much needed biography of one of the legendary figures in American medicine and higher education. Once again Thomas Bonner has shown that he is one of the great medical historians of our time."--Kenneth M. Ludmerer, Washington University
Book Description
In this, the first biography of Abraham Flexner (1866--1959), distinguished scholar Thomas N. Bonner offers an engaging and insightful view of one of the most influential figures in twentieth-century American education. From his early, pathbreaking work in experimental primary schools to the founding of the prestigious Institute for Advanced Study at Princeton, Abraham Flexner's influence on American education was deep, pervasive, and enduring. In Thomas N. Bonner, Flexner has at long last found the biographer that his critical role in American education deserves.The son of poor Jewish immigrants in Louisville, Kentucky, Flexner was raised in the Reconstruction South and educated at the Johns Hopkins University in the first decade of that institution's existence. Upon earning his degree in 1886, he returned to Louisville to found -- four years before John Dewey's Chicago "laboratory school" -- an experimental school based on progressive ideas that soon won the close attention of Harvard President Charles Eliot. After a successful nineteen-year career as a teacher and principal, he turned his attention to medical education. His 1910 survey -- known today as the Flexner Report -- stimulated much-needed, radical changes in the field and, with its emphasis on full-time clinical teaching, remains to this day the most widely cited document on how doctors best learn their profession. Flexner's subsequent projects -- a book on medical education in Europe and a comparative study of medical education in Europe and America -- remain unsurpassed in range and insight. For fifteen years a senior officer in the Rockefeller-supported General Education Board, he helped raise money -- more than 6 billion in today's dollars -- for education in medicine and other subjects. His devastating critique of American higher education in 1936 raised the hackles of educators -- but ultimately raised important questions as well. Three years later he created and led the Institute for Advanced Study in Princeton, convincing Albert Einstein to accept the first appointment at the newly created institute.Brilliant, abrasive, tenderhearted, and fundamentally a decent, farseeing man, Abraham Flexner accomplished much good in the world. His story, based on new archival sources and told with verve and wit, is sure to become the definitive work on a man and his era.
About the Author
Thomas N. Bonner is Distinguished Professor Emeritus and President Emeritus of Wayne State University. He is the author of five books on the history of medicine and education, and two textbooks. He has been awarded two Guggenheim Fellowships and was a Rockefeller Foundation Resident at Baellagio, Italy. The former president of three universities and colleges--the University of New Hampshire, Union College, and Wayne State University--he is the recipient of major, multi-year grants from the National Endowment for the Humanities and the National Institutes of Health, and has been awarded three honorary degrees.
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